"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

July 17, 2013

MERS as medical thriller

Watching MERS unfold, I've felt as if I were reading a long, ungainly thriller that wasn't going anywhere. Fiction writers, novices and veterans alike, know the feeling: Their inner editors are reading the stuff on the screen and uttering low, despairing moans from their subconscious dungeons.

When the moans get loud enough, novices often give up in despair. They know something's wrong with the story, but they have no idea what it could be. They don't even have an editor with a shoulder to cry on, so another ambitious project goes into the ditch and writer's block settles in.

The remedy is to free their inner editor, just as a publisher's editor can often identify the problems in a developing story. When I ran into this problem, I gave the keyboard over to my inner editor, who could be far more brutal than a real one.

The problems would spill out: too much verbiage, too much expository dialogue ("As Pasteur pointed out long ago..."), two-dimensional characters, not enough conflict. And on and on. But this was not an exercise in masochism; it was a way to solve the problems by articulating them, and it worked amazingly well. Simply by framing the problems in simple sentences, I seemed to set my mind up to create solutions. Then I'd write a little more to explore the implications of those solutions, save the file for return visits with my inner editor, and go back to the manuscript.

If I were writing such an editorial letter to myself about MERS, my big complaint would be the diffuse plot. After all, the first cases turned up over a year ago in Jordan, caused a brief local flurry, and then vanished—as did Jordan from the story.

Then cases began to pop up in the fall of 2012 and spring of 2013, in the Gulf, with exported cases appearing in various European countries. That's an OK plot twist, because it shows us what's at stake. But they weren't developing any suspense, and H7N9 turned up with a much more unified storyline. Mercifully, that turned into a self-contained plot strand that could be safely cut and saved for a future thriller.

Suspense finally turned up with the recent spate of Saudi cases. Now we're getting somewhere! An exotic and wealthy locale, the threat of a pandemic erupting among the pilgrims, millions of expatriate workers whose values may be exacerbating the situation—lots of possibilities here. Hey, we've even got a ministry of health whose MERS bulletins are maddeningly brief. Surely they must be hiding something.

This is a kind of whodunit (or whatbugdunit), and it needs a protagonist, a detective of some kind. Tough to do plausibly in this case, because modern global health is a vast enterprise involving scores of thousands of brilliant people. But let's say a special committee forms, with experts from various epidemic-intelligence agencies. Now we have political complications, not to mention the hazards posed by various epidemiological prima donnas the team must consult.

A junior member of the committee might be the hero—a veteran of earlier epidemics, familiar with the Middle East, one of those driven doctors like those in MSF who've worked in dismal conditions. She does good work, but she's run afoul of the Saudis before and is no longer welcome in the Kingdom.

She's stuck in a kibitzer's job, maybe in an office in Geneva or Stockholm, which means she's getting a steady stream of news but no hands-on action. As the number of MERS cases grows, she becomes increasingly frustrated. The origins of the virus remain unknown, some of the medical prima donnas are squabbling about intellectual-property issues, and the Hajj looms ever closer.

Finally the committee reaches an impasse, reduced to issuing news releases about hand-washing, and our hero's criticism of her colleagues makes her unpopular. After a confrontation, she's effectively fired—transferred to Jordan.

Once there, however, she heads straight for Zarqa and the hospital where the first MERS cases and deaths were reported. She visits the homes of the survivors, listens to the doctors and nurses, and gains their trust. Eventually, someone mentions something about the index case, a healthcare worker who'd gone on a trip to a forgotten village and then come back and fallen ill.

You can write the rest of the story yourself: Hero goes to village, finds a neglected well or cave where bugs or bats or camels are found, takes some samples, and alerts a buddy at the Netherlands' best lab. The samples identify the source critter, our hero makes some frantic Skype calls, and the Hajj goes off without a hitch. With the right agent, we can turn the thriller into a series, like the Wallender novels only not as depressing.

That's how a pulp novelist would tell the story anyway, and no doubt the reality is far less exciting. But I am surprised that we don't know far more about the Jordanian cases than we do: Who was the index case, how did the outbreak progress, what were the patients' medical histories, where were they from...until we finally found something, some contact that set the whole MERS plot rolling forward.

And even if the origin of MERS wasn't in Jordan, it would be good to know what the medical detectives did there last year.

Comments

MERS as medical thriller

Watching MERS unfold, I've felt as if I were reading a long, ungainly thriller that wasn't going anywhere. Fiction writers, novices and veterans alike, know the feeling: Their inner editors are reading the stuff on the screen and uttering low, despairing moans from their subconscious dungeons.

When the moans get loud enough, novices often give up in despair. They know something's wrong with the story, but they have no idea what it could be. They don't even have an editor with a shoulder to cry on, so another ambitious project goes into the ditch and writer's block settles in.

The remedy is to free their inner editor, just as a publisher's editor can often identify the problems in a developing story. When I ran into this problem, I gave the keyboard over to my inner editor, who could be far more brutal than a real one.

The problems would spill out: too much verbiage, too much expository dialogue ("As Pasteur pointed out long ago..."), two-dimensional characters, not enough conflict. And on and on. But this was not an exercise in masochism; it was a way to solve the problems by articulating them, and it worked amazingly well. Simply by framing the problems in simple sentences, I seemed to set my mind up to create solutions. Then I'd write a little more to explore the implications of those solutions, save the file for return visits with my inner editor, and go back to the manuscript.

If I were writing such an editorial letter to myself about MERS, my big complaint would be the diffuse plot. After all, the first cases turned up over a year ago in Jordan, caused a brief local flurry, and then vanished—as did Jordan from the story.

Then cases began to pop up in the fall of 2012 and spring of 2013, in the Gulf, with exported cases appearing in various European countries. That's an OK plot twist, because it shows us what's at stake. But they weren't developing any suspense, and H7N9 turned up with a much more unified storyline. Mercifully, that turned into a self-contained plot strand that could be safely cut and saved for a future thriller.

Suspense finally turned up with the recent spate of Saudi cases. Now we're getting somewhere! An exotic and wealthy locale, the threat of a pandemic erupting among the pilgrims, millions of expatriate workers whose values may be exacerbating the situation—lots of possibilities here. Hey, we've even got a ministry of health whose MERS bulletins are maddeningly brief. Surely they must be hiding something.

This is a kind of whodunit (or whatbugdunit), and it needs a protagonist, a detective of some kind. Tough to do plausibly in this case, because modern global health is a vast enterprise involving scores of thousands of brilliant people. But let's say a special committee forms, with experts from various epidemic-intelligence agencies. Now we have political complications, not to mention the hazards posed by various epidemiological prima donnas the team must consult.

A junior member of the committee might be the hero—a veteran of earlier epidemics, familiar with the Middle East, one of those driven doctors like those in MSF who've worked in dismal conditions. She does good work, but she's run afoul of the Saudis before and is no longer welcome in the Kingdom.

She's stuck in a kibitzer's job, maybe in an office in Geneva or Stockholm, which means she's getting a steady stream of news but no hands-on action. As the number of MERS cases grows, she becomes increasingly frustrated. The origins of the virus remain unknown, some of the medical prima donnas are squabbling about intellectual-property issues, and the Hajj looms ever closer.

Finally the committee reaches an impasse, reduced to issuing news releases about hand-washing, and our hero's criticism of her colleagues makes her unpopular. After a confrontation, she's effectively fired—transferred to Jordan.

Once there, however, she heads straight for Zarqa and the hospital where the first MERS cases and deaths were reported. She visits the homes of the survivors, listens to the doctors and nurses, and gains their trust. Eventually, someone mentions something about the index case, a healthcare worker who'd gone on a trip to a forgotten village and then come back and fallen ill.

You can write the rest of the story yourself: Hero goes to village, finds a neglected well or cave where bugs or bats or camels are found, takes some samples, and alerts a buddy at the Netherlands' best lab. The samples identify the source critter, our hero makes some frantic Skype calls, and the Hajj goes off without a hitch. With the right agent, we can turn the thriller into a series, like the Wallender novels only not as depressing.

That's how a pulp novelist would tell the story anyway, and no doubt the reality is far less exciting. But I am surprised that we don't know far more about the Jordanian cases than we do: Who was the index case, how did the outbreak progress, what were the patients' medical histories, where were they from...until we finally found something, some contact that set the whole MERS plot rolling forward.

And even if the origin of MERS wasn't in Jordan, it would be good to know what the medical detectives did there last year.